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Coping with a bipolar father living in rural Bhutan

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In February, I received a call from my second brother in Nichula, Bhutan, telling me that my father was experiencing another manic episode – a condition he has suffered from for more than 23 years without receiving any medical attention.

This time was different. My brother said my father had escaped into the forest and had made his way to the border and the cattle ranching site where he had lived for years. He had no sense of the restrictions on cross-border movement at the Indo-Bhutan border, so had, unintentionally, breached the Covid protocol in place.  

His unauthorised journey had attracted the attention of a group of government officials, including the new dzongda (chief district officer) of Dagana district, Duba Yonten, who travelled to our family home and saw my father’s condition. The authorities considered the matter seriously and took him to Kalikhola hospital for isolation. My youngest brother escorted him.

A year earlier, my father lived in Gelephu where he was able to visit a doctor on a regular basis and receive treatment. Despite displaying the symptoms of bipolar disorder, he was not admitted to the hospital. Instead, he was prescribed medicine for chronic gastritis and high blood pressure. Such medication didn’t help his condition because his mental disorder was not considered to require treatment. 

 In 2016 my second brother took my father to visit the psychiatrist and gastro specialist, Dr. Damber Nirola, in Thimphu who referred him to Dr. Guru Dhakal who carried out an endoscopy. His diagnosis was that my father’s ailments were more to do with his mental health than his digestive system. 

Visiting doctors in Thimphu hospital is difficult  for villagers living in isolated hamlets such as Nichula. There is little health awareness in such remote rural areas, and follow-up appointments are usually carried out verbally. If a patient does not return for follow-up the doctors or health care workers do not have an obligation to call them back.

Thanks to the free healthcare system in Bhutan, access doesn’t depend on the economic status of those needing help, but much depends on the patient’s ability and knowledge to seek medical help.

In illiterate societies there is often prejudice and ill-informed gossip when it comes to issues to do with mental health. Rural life in Bhutan is rife with such prejudice and stigma about mental health in the same way that people used to fear leprosy. 

Many in the village thought my father was arrogant, belligerent, and a man who had a bad mouth. No one understood that his bipolar disorder made him act the way he did. His relationship with the overpowering Gup (the village head) and with some relatives deteriorated during this period.

After a month-long stay in an isolation ward and general ward, my father was discharged in March. Doctor Chhimi made an appointment for him to return in a week. Using medication such as Sodium Valproate and Risperidone his manic episodes have abated. But it is the beginning of a long process aimed at keeping his mental state healthy. Our family also needed help understanding what they could do to help my father, along with counseling to help them understand, manage and take care of episodes. Doctor Chhimi told me, “Limited resources are available locally for alternative care like psycho-social counseling and cognitive behavioral therapy. Those are available only in Thimphu”

A complete lack of understanding about the episodes my father was experiencing, the early symptoms, his adult life characteristics, and his bipolar syndrome leaves the uninformed thinking he has “gone mad”.   

Psychiatric care remained out of bound for the family, and my brothers and sisters didn’t have the capacity to take him to Thimphu every time the episodes occurred. Some dismissed my father’s condition saying that he had been “like that” from the beginning.

Yes, he had been abusive at times, raising his hands and waving sticks if a person didn’t do what he wanted. And, yes, it was hard to understand why he slapped my mother. We just thought his actions were the result of his uncontrolled anger about small things. My mother always showed  tolerance and patience in coping with her abusive husband despite not knowing why he acts the way he did. 

Outside our home my father still arouses stigma within the family. In 2018, we met in Jaigaon and planned a cultural tour to Kathmandu. My mother refused to go. During his interaction with the relatives we met my father was blurting out accusatory words against my brothers and my mother. I too felt the stigma, because he wouldn’t stop shouting at and disparaging his own children. He came to meet me at the height of his psychosis, and, fortunately, I was able to spot the signs and understand what he was going through. With the medicines prescribed by Dr. Nirola, we were able to make a success of our trip.

The stigma probably caused my second brother to shy away from seeking medical help even when my father needed it. During regular conversation over messenger he reiterated, ‘treatment doesn’t help our father’. This frustration left him with less empathy. 

The cause of my father’s bipolar disorder is still unclear. Perhaps suffering two stressful attacks contributed. 

In 1993/94 a group of armed robbers assaulted him, almost stabbing him to death. My father wanted to die in his country, not leaving it for no fault of his and not heeding the threats. This led to family separation, with children not able to go school, and the pressure to go three months of ‘gongda-woola’(conscripted form of labor) along with the armed Indian separatists roaming around the village. Another time he was assaulted by a neighbor who was an influential man in the village. As always, stigma has prevailed. 

My brothers don’t have the time and resources to take my father to visit the psychiatrists in Thimphu. He lives on a cattle ranching site in the  Phibsoo Wildlife Sanctuary and Assam Forest, and my brothers have been unable to convince him to take his regular medications. He did not go back to see a doctor or health worker even in Kalikhola when they asked him. Interestingly, no doctors or health care workers in Kalikhola or Gelephu hospital felt it necessary for him to be offered inpatient services. Even Dr. Nirola, the psychiatrist in Thimphu, did not suggest he be admitted when they visited him in 2016. Perhaps my father’s condition was not considered to be urgent at the time.

When I talked to Dr. Chhimi in Kalikhola hospital, she assured me that they would take responsibility for my father if he ever escaped to the jungle or reached the border again. That gave me some relief that they have taken his illness seriously. I tried to help my family understand  that they must follow the instructions of medical professionals, continue to ask questions, and seek alternative ways for care.

For people in Nichula, commuting to Kalikhola for government service or medical care is an economic hassle. In fair weather, bolero pick up charges Ngultrum 1200 to 1800 for a mere 14 km of reserved travel. Sick people definitely need a reserve vehicle to reach the hospital on time. Given this exorbitant rate of travel, chances are high that people avoid such medical care unless there is an emergency. Access to free health care sponsored by the government is presumably restricted for those living in isolated villages like Nichula. My brother told me he could bring father home at no cost on transportation thanks to the gewog vehicle available on March 9, but paid 2400 for two segments of the trip for follow-up appointment on March 16. 

Last July, my aunt, my father’s only sister, died while being carried on shoulders to reach the nearest available transportation.

The Nichula gewog (a village constituency) falls within the protected area system. People are living in harmony with nature, but they are not without disease, or illness. The physical, social, spiritual and emotional well-being of that small rural population is probably not on the agenda of local development committees. 

The local leaders get handsome perks from the government, but for nothing to take responsibility for the welfare of constituencies. The Nichula gup ( the village headman) lives in Kalikhola, the Tshogpa (the assistant headman)gets Ngultrum 1000 daily allowance for attending one-day meeting. If GNH accounts for the non-material well-being of the people, and if conservation of the natural environment has a positive impact on the lives of people, why do five people in Nichula still suffer mental illness?

It appears the local government has not done enough for the people living under the constant threat of wild animals and there is no consideration for any crop damage caused. There is no health care extended to the village, and the sheer difficulty involved in transporting goods and human beings during monsoon remains an acute problem. As a normal practice, people living in protected areas should be given more incentives for being the stewards of conservation providing health care, education, economic incentives, chronic disease management and empowerment programs through sustainable harvesting of natural resources.

Enough is not done to make people feel they belong to a larger Bhutanese community. My brother often said, “Why didn’t our father opt to leave this place, when all our extended families left.”

______

The author is one of the contributing editors of BNS

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